smith m, yuan x, harris e, lechanski l, parson n, condon r

Abstracted accepted for a poster session at the 2025 Military Health System Research Symposium

Introduction: Trigger point dry needing (TPDN), also known as dry needling, is an intervention employed by a myriad of providers to treat musculoskeletal (MSK) conditions. This technique uses the insertion of a solid filament needle without medication to treat scarring, myofascial pain and mobility, and muscle motor recruitment dysfunction. Active duty Service Members (ADSMs) are at an increased risk for developing MSK conditions due to their occupational and fitness requirements. Although studies have explored TPDN within this population, supporting use within clinic and deployed environments, most of current literature is lower quality and heterogenous. The study aims to obtain quantitative and qualitative data regarding the current TPDN practices of clinical providers within the Military Health System (MHS).

Methods: This cross-sectional survey-based study was approved with exempt determination by the U.S. Army Medical Center of Excellence Office of Research and Human Subject Protections (24-00027e). Active duty and civilian clinical providers within the MHS are invited to complete the 33-question survey with the aim of attaining 250 respondents. Training, experience level, safety, outcomes, and barriers to clinical practice will be evaluated. Continuous variables will be presented as means with standard deviations or medians with interquartile ranges. Categorical variables will be presented as counts and proportions. Hypothesis testing will be performed at the 5% significance level, as applicable.

Results: To date, 13 clinicians (13 physical therapists) have completed the survey. 12 respondents currently perform TPDN, and 1 respondent has performed TPDN in the past. Additional analyses will be available at time of report.

Conclusion: MHS providers have been employing TPDN as a cost-effective, low risk and minimally invasive intervention to treat MSK conditions. Considering military personnel can be deployed in a variety of environments, where resources may be scarce, having a minimally invasive intervention at the fingertips of deployed medical personnel is valuable. The results of this study will better inform prospective research protocols to determine the TPDN efficacy in terms of pain reduction, functional improvement, and operational readiness. The survey will also help guide the establishment and standardization of training and clinical practice guidelines, optimize safety and maximize level of confidence/comfort with performing TPDN.

e super, m smith, m miller, j smith, x yuan

Objectives: Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy. Anatomic variations of the median nerve (MN) and carpal tunnel (CT) may predispose patients to CTS or increase procedural complexity and risk during carpal tunnel release (CTR). This study aimed to systematically evaluate the prevalence of 25 MN and CT anatomic variations and measurements using ultrasound (US) in patients referred for electrodiagnostic testing (EDX).

Methods: In this cross-sectional observational study, patients underwent diagnostic US exams of the MN (mid-brachium to distal CT), focused on variant anatomy that may predispose to CTS (bifid MN, Gantzer's muscle, lumbrical intrusion) or increase procedural complexity/risk (transligamentous thenar motor branches [TMBs], MN orientation ulnar to the palmaris longus [PL] tendon).

Results: Two hundred and twenty patients (mean age: 45.3 ± 13.0 years; 63.6% male; 294 UEs) were evaluated by US. Hundred and eight UEs met EDX criteria for CTS (EDX-CTS). The most common variations identified were lumbrical intrusion (81.3%), Gantzer's muscle (39.5%), and persistent median artery (22.8%), which were not associated with EDX-CTS. US revealed transligamentous (2.4%) and ulnar origin (4.5%) TMBs, which may increase injury risk during CTR. MN location was ulnar to the PL tendon in 70.4% of wrists, which can predispose to injury during landmark-guided CT injections.

Conclusions: This study demonstrated that US complements EDX and can systematically identify anatomic variations, including variants at risk during CTS interventions. No differences in the prevalence of variations were detected between patients with and without EDX-CTS. Diagnostic US can support procedural planning, improve safety, and lower injury risk.

Super EJ, Smith MS, Miller ME, Smith J, Yuan X. Ultrasonographic Assessment of Median Nerve and Carpal Tunnel Variations: Implications for the Interventional Management of Carpal Tunnel Syndrome. J Ultrasound Med. 2025 Jun 18. doi: 10.1002/jum.16733. Epub ahead of print. PMID: 40530498.

c fellin, r steiner, x yuan, s jariwala

Collagen-based biomaterial inks for digital light processing (DLP) 3D printing are particularly attractive due to their inherent biocompatibility, cell-adhesion properties, and biodegradability. However, there have been relatively few examples of collagen-based biomaterial inks without the use of synthetic co-monomers or specialized printing equipment. Furthermore, photo-crosslinked collagen hydrogels are often brittle, limiting their use in biomedical applications and regenerative medicine. In this study, we present the development of a novel collagen-based biomaterial ink for DLP 3D printing, enabling the fabrication of robust hydrogel constructs through a post-print tannic acid (TA) treatment. The biomaterial ink, composed of collagen methacrylate (ColMA) and a natural co-monomer, hyaluronic acid methacrylate (HAMA), achieves high-resolution printing of biomimetic structures. The post-print TA treatment (0.25–30 mg/mL) significantly increases mechanical strength, improves degradation rates, and reduces the size and porosity of the resulting dual-crosslinked, hybrid network structures. The biocompatibility of these constructs was assessed using adult human dermal fibroblasts, revealing optimal cell viability and adhesion at low TA concentrations (0–0.25 mg/mL). Furthermore, the antioxidant capacity of TA-treated biomaterials was evaluated, demonstrating potential for applications in environments with high reactive oxygen species (ROS). Overall, this collagen-based biomaterial ink and post-print TA treatment offers a promising solution for the DLP 3D printing of tough, biodegradable, and biocompatible constructs for biomedical applications in regenerative medicine.

Fellin, C. R., Steiner, R., Yuan, X., & Jariwala, S. H. (2025). A collagen-based biomaterial ink for the digital light processing 3D printing of tough, dual-crosslinked hydrogels via post-print tannic acid treatment. Bioprinting, 50, e00422. https://doi.org/10.1016/j.bprint.2025.e00422

d dmytriiev, q liu, m barsa, a khomenko, a strokan, p pasquina, s cohen

Introduction This exploratory study investigates the potential of perineuromal hydrodissection as an adjunct to opioid therapy for postamputation pain, specifically focusing on residual limb and phantom limb pain (PLP). Given the correlations between acute pain and the development of chronic pain, the primary aims were to estimate the effect size of early hydrodissection of scar tissue around residual limb neuroma(s) and to identify the best time frame for treatment.

Methods Seventy-four patients with war-related limb amputations and painful neuromas were included in this observational analysis. Thirty-eight Ukrainian patients with war-related limb amputation and a painful neuroma(s) who underwent hydrodissection and opioid therapy within 6 months of amputation were compared with 36 patients who received opioids alone. Co-primary outcome measures were median reduction from baseline in average residual limb and PLP at 12 weeks. The composite positive outcome was designated as a ≥2-point decrease or 30% reduction in average residual limb and PLP, satisfaction with treatment, and not requiring an increase in analgesics.

Results Hydrodissection as an add-on to opioids resulted in a greater reduction in average residual limb pain at 12 weeks (−2.00±1.00 vs −1.00±1.00; p<0.001) and earlier time periods, but PLP only through 4 weeks. At 12 weeks, Hospital Anxiety and Depression Scale anxiety (10.00±2.00 vs 11.00±1.00; p<0.001) but not depression score was lower in the hydrodissection group. Opioid use in the hydrodissection group significantly declined from 41.32±9.63 to 33.42±8.78 morphine equivalents per day (p=0.001) over the study, but not in the opioid-only group (p=0.20). Differences in 12-week satisfaction rates were not significant.

Conclusions This exploratory study suggests perineuromal hydrodissection may improve residual limb pain and to a lesser degree phantom limb pain, particularly when implemented early in the course of postamputation pain. The study provides preliminary effect size estimates and identifies acute pain as a potential characteristic of patients who may respond more favorably to this intervention. Randomized controlled trials are needed to confirm these findings and control for the confounding variables identified.

Dmytriiev D, Liu W, Barsa M, Khomenko A, Strokan A, Pasquina P, Cohen S. Perineuromal Hydrodissection for Acute Postamputation Pain? An Observational Study in a Time of War. Regional Anesthesia & Pain Medicine Published Online First: 19 February 2025. doi: 10.1136/rapm-2024-106307

w liu, e gelderen, r mawalkar, e wang, g treisman, s cohen

Background: Difficult encounters represent an enormous burden and drain on resources in pain medicine, but their effect on outcomes has not been studied.

Objective: To determine the effect of “difficult” encounters on chronic pain outcomes.

Methods: In this prospective study, new chronic pain visits were rated by an attending physician and trainee on a 6-point Likert scale and stratified into “difficult” and “non-difficult.” The main outcome was successful treatment, defined as a ≥2-point reduction in average pain 4 weeks after initiation of pharmacological, integrative, or simple injection therapy, or 12 weeks after more invasive procedures. The secondary outcome was being lost to follow-up.

Results: Among 428 patients seen for new-patient evaluations, 299 patients had follow-up, of whom 127 (42.5%) experienced a positive outcome. Patients involved in difficult encounters were less likely to experience a positive outcome (28% vs 46%; P = .02) than those not involved in difficult encounters. When stratified into quartiles, difficulty continued to be associated with an unsuccessful outcome, with the easiest encounters translating to a 53% success rate, versus 28% for patients involved in the most difficult encounters (P = .02). Difficult encounters were not associated with loss to follow-up. In multivariable analysis evaluating factors associated with difficultness, missing ≥10% of appointments (OR 0.69, 95% CI: 0.48–0.97; P = .04), non-organic signs (OR 0.42, 95% CI: 0.18–0.90; P = .03), visit taking longer than expected (OR 0.49, 95% CI: 0.25–0.96; P = .04), and refusal to try a treatment (OR 0.25, 95% CI: 0.08–0.70; P = .01) were associated with poor outcome.

Winnie L Liu, Evelien van Gelderen, Resham Mawalkar, Eric J Wang, Glenn Treisman, Steven P Cohen, Do difficult encounters affect pain treatment outcomes? A prospective cohort study, Pain Medicine, 2025;, pnaf027, https://doi.org/10.1093/pm/pnaf027

m Mullinax, i sorensen, j dintaman, e hisle-gorman

Research suggests injury/disability type and individual demographic factors both impact return-to-work trajectories of those with injuries/disabilities. These questions of disability and return to work/service are particularly relevant to the military where service members are at increased risk of experiencing work-related physical and mental health injuries. The Army Warrior Care and Transition Program (WCTP) is a comprehensive rehabilitation program launched in 2007 to address injured service members’ needs. We sought to understand the WCTP’s efficacy in returning soldiers with physical and mental health injuries to military service (including active duty, Reserve, and Guard).

Melissa Mullinax, Ian Sorensen, Jay Dintaman, Elizabeth Hisle-Gorman, Effect of Serious Mental Health and Physical Injuries and Their Treatment on Career Trajectories for Military Service Members, Military Medicine, 2025;, usaf191, https://doi.org/10.1093/milmed/usaf191

goss d, gaunaurd i, rochester k, helton m, marshall a, reilly n, melton c, gailey r

Abstract accepted for podium presentation at the 2025 Naval Medical Center Camp Lejeune Research Symposium

Musculoskeletal injuries (MSI) are very common in the military population and even more common with very active and elite paratroopers in the 82nd Airborne Division.  Potter et al. published a one-year prospective cohort study in 2002 in Military Medicine outlining these injuries.  They followed 1,965 paratroopers in from Fort Bragg in 1996. These soldiers suffered 508 overuse injuries (including 38 stress fractures), 1,415 traumatic injuries (including 100 fractures), and 101 unclassified injuries. Injury rates were 6.8% per soldier per month for traumatic injury and 2.4% for overuse injury (totaling 1.2 injuries per soldier per year). Injuries resulted in 22,041 limited duty days, averaging 11 days per injury and 13 days per soldier (4.5% of total workdays). Fractures and stress fractures/reactions produced the most days lost per case. Most of these injuries resulted from military specific activities.

As part of a prospective injury prediction protocol involving knee sensors analyzing single leg stance and a side shuffle task, our Musculoskeletal Injury Rehabilitation Research for Optimal Readiness (MIRROR) team enrolled and screened 1183 soldiers from the 82nd Airborne Division at Fort Bragg/Liberty, NC from fall 2022 to fall 2023 with 6- month and 12-month MSI incidence evaluated in the electronic medical record (AHLTA and Genesis).

These results highlight the types of injuries an active group of soldiers from the 82nd Airborne Division are experiencing and can help to guide prevention and treatment strategies going forward.

m kasper, m smith, s simmons, c campbell, s cohen, s wilson

Abstract accepted for poster presentation at USU Research Days 2025.

Active duty Service Members may be at increased risk for developing knee osteoarthritis  (KOA) due to the fitness demands and predisposition for traumatic joint injuries. Military and civilian  patients may benefit from alternative procedures including genicular radiofrequency ablations (RFA).

Case 1 is a 56-year-old male retiree with chronic knee pain (> 5 years) and radiographic evidence of left KOA [Kellgren-Lawrence (KL) Score: 2]. Case 2 is a  79-year-old male retiree with chronic right knee pain (1-5 years) and radiographic evidence of right KOA (KL Score: 1). Both patients received genicular RFA procedures targeting nine nerve sites: superomedial, superolateral, inferomedial, inferolateral genicular nerves, nerve to vastus medialis, medial branches of  nerve to vastus intermedius, nerve to vastus lateralis, lateral branches of nerve to vastus intermedius,  and infrapatellar branch of the saphenous nerve. Patient-reported outcome measures [i.e., Knee Injury  and Osteoarthritis Outcome Score-12 (KOOS-12), Modified 4-Item Brief Pain Inventory Scale (mBPI)] were collected at baseline and 12 weeks post-procedure.

By day 7 post-procedure, both patients reported their knee pain to be very much improved and  0/10. mBPI scores (Case 1: -4.75; Case 2: -3) and KOOS-12 subscale scores for pain (Case 1: -1; Case 2: - 6), function (Case 1: -3; Case 2: -6), and quality of life (Case 1: -1; Case 2: -3) improved in both patients at  12 weeks post-procedure.

These cases demonstrate the modified genicular RFA technique can yield symptom relief as  soon as 1-week post-procedure, with overall improvement out to 12 weeks, which is consistent with  non-randomized studies demonstrating better improvement with targeting more nerves (nine versus  traditional three). These study results may support expansion of effective conservative treatment  options for military beneficiaries with KOA.

j galvin, p rooney, a Egan, j tokish, j grassbaugh, b masini, k free, m bastian, l gillette, z colburn

The purpose of this study was to compare gene expression differences in the blood and tissue of patients with anterior shoulder instability with and without significant glenoid bone loss (GBL). The hypothesis was that the severity of GBL would be associated with the expression level of genes in the blood and capsular tissue of patients with anterior shoulder instability.

Consecutive patients with anterior shoulder instability undergoing arthroscopic and open shoulder stabilization were prospectively enrolled. Blood and anterior capsular tissue specimens obtained during surgery were compared between patients with significant GBL (≥10%) and patients without significant GBL (<10%). RNA was extracted, and a panel of 277 inflammatory genes was utilized to quantify gene expression at the RNA level using a probe-based RNA quantification platform. Differential expression analysis was performed to identify genes expressed at different levels between patients with and without significant GBL. The expression levels of the subset of genes identified were used to generate a ridge regression model to predict the severity of GBL. Quantitative polymerase chain reaction was performed to confirm probe-based RNA findings.

A total of 17 patients were included, with a mean age of 26 years. Overall, 7 patients had <10% GBL (mean, 2.3%), and 10 patients had ≥10% GBL (mean, 16.4%). There were 9 genes that were identified as significantly differentially expressed in the blood, and 5 of these (IFIT1, IFIT3, IFI44, PRKCB, and OAS2 with P values of 1 × 10−5, 1 × 10−4, 1 × 10−4, 1 × 10−4, and 6 × 10−4, respectively) were confirmed using nonparametric tests. The authors developed a model using the 5 genes to predict the severity of GBL, and this had an accuracy of 88% (95% CI, 64%-99%). By quantitative polymerase chain reaction, IFIT3 was confirmed to be significantly differentially expressed (P = .012).

Galvin JW, Rooney P, Egan A, Tokish JM, Grassbaugh JA, Masini B, Free KE, Bastian MK, Gillette LH, Colburn ZT. Transcriptomics of Anterior Shoulder Instability: Differences in Gene Expression in the Blood of Patients With and Without Significant Glenoid Bone Loss. Orthopaedic Journal of Sports Medicine. 2025;13(5). doi:10.1177/23259671251336394

D rhon, s george, n parsons, j fritz

Beliefs can affect perceived harms and benefits of a treatment. The purpose of this study was to assess the relationship between beliefs about exercise and surgery effectiveness and pain interference and physical function in patients with non-specific low back pain. This was a cohort of 629 pooled clinical trial participants receiving non-pharmacological pain management. Participants either agreed (somewhat or completely) or disagreed that surgery would be beneficial or that exercise would make their symptoms worse. Those that agreed were categorized as having high expectations about the treatment. The influence of high expectations on short-term (6-week) and long-term (6-month) PROMIS Pain Interference scores was modeled with generalized linear (Gaussian) models. In a subset of 510 patients, the same analysis was conducted using PROMIS Physical function scores. The cohort was 28.8% female, mean(SD) age of 33.4(8.3) years and 83.1% active-duty. In all 67.1% had low expectations of exercise and 11.0% had high expecations of surgery. High expectations for surgery were not a significant predictor of pain interference or physical function. High expectations for exercise predicted lower pain interference (ß=−2.146, 95CI −3.366, −0.926; P<0.001) and higher physical function (ß=1.807, 95CI 0.586, 3.027; P=0.004) at 6 weeks and 6 months. High expectations for exercise were uncommon (about 33%) but associated with better outcomes out to six months. One in 10 patients had high expectations for surgery but this was not associated with outcomes. A better understanding of treatment expectations may present opportunities to improve engagement and education strategies for patients with low back pain.

Rhon D, George S, Parsons N, Fritz J. Expectations About the Benefit of Exercise, Not Surgery, are Associated with Future Pain and Physical Function in Patients with Non-Specific Low Back Pain. The Journal of Pain, Volume 31. 2025. 1526-5900. https://doi.org/10.1016/j.jpain.2025.105414.

A Sheean, m tenan, M defoor, d cognetti, a bedi, a lin, t dekker, motion collaborative, j dickens

There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population’s fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of 2 different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operating characteristic (ROC) curve–based MCIDs and baseline-adjusted ROC curve MCIDs.

All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROM battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Patient Reported Outcome Management Information System (PROMIS) physical function (PF), PROMIS pain interference (PI), and the Warfighter Readiness Survey. Standard anchor-based and baseline-adjusted ROC curve MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval [CI] either completely negative or positive).

A total of 117 patients (136 operations) were identified, comprising 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC curve MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC curve MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7.

When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC curve analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC curve method was more effective at discerning changes across a battery of PROMs among the same cohort.

Sheean AJ, Tenan MS, DeFoor MT, Cognetti DJ, Bedi A, Lin A, Dekker TJ; MOTION Collaborative; Dickens JF. Minimal important clinical difference values are not uniformly valid in the active duty military population recovering from shoulder surgery. J Shoulder Elbow Surg. 2024 Nov;33(11):e596-e605. doi: 10.1016/j.jse.2024.02.044. Epub 2024 Apr 16. PMID: 38614369.

t velasco, n reilly, c hulsopple, k roberts, s wise, d goss, j leggit

Abstract accepted for poster presentation at the ATAMMC Research Symposium 2025.

Background and Purpose: Chronic exertional compartment syndrome (CECS) is a debilitating condition for soldiers marked by lower-limb pain, paresthesia, and weakness1,2. While the gold standard treatment has long been fasciotomy, anecdotal data shows mixed results and limited predictive success following the procedure3,4. Alternative approaches to treating CECS have included pharmaceutical interventions (i.e., Botulinum toxin, BoTN-A)5,6 and structured gait retraining to ameliorate movement patterns7. However, the incorporation of a combination of non-surgical interventions for CECS has not been extensively studied in military personnel. Thus, the purpose of this case study was to evaluate a multimodal combination of treatment approaches for CECS in a soldier to identify an efficacious way to address running parameters and reduce pain to improve function.  

Case Description: A 27-year old female Soldier diagnosed with bilateral anterior and lateral lower leg CECS was recruited to participate in a larger cohort study.  She received saline injections and supervised gait retraining, including strengthening and flexibility exercises. The participant had their running gait assessed using pressure-sensitive insoles (LoadSol, Novel USA, St. Paul, MN) at the initial treatment, after 8-weeks, 3-months, and 6-months. Time points of 12- and 24-months running assessments were not collected as she moved out of network. Between the 3- and 6-months visit, the participant elected to cross-over treatment therapies and received BoTN-A. Clinical metrics included numeric pain rating scale (NPRS), the Single Assessment Numerical Evaluation (SANE) and University of Wisconsin Running Index (UWRI), as well as the Global Rating of Change scale (GROC). These metrics were obtained up to 24 months post initial injection.

Outcomes: From baseline to the 3-month mark, the participant showed improvement on clinical metrics including a 90.9% increase in UWRI and a GROC of 5. These metrics are accompanied by a 22.5% increase in cadence and a 10.2% decrease in peak ground reaction force (GRF). Notably, the patient still reported an NPRS of 5/10 (7/10 baseline) with running at 3-months. Following the BoTN-A injections, the participant at 6-months displayed a 17.9% decrease in average vertical loading rate (AVLR) and a 2.0% decrease in peak GRF. Clinically, she displayed improvements in UWRI of 47.6%, SANE of 20.0%, and a GROC of 6, along with NPRS of 0/10 with running. At 12-months, NPRS remained at 0/10 with running, but UWRI and GROC scores slightly decreased, likely from her reported knee injury. At 24-months, the participant reported no pain with running and perfect SANE, UWRI, and GROC scores.

Discussion: This case study demonstrates gait retraining can be beneficial for improving pain and function in soldiers with lower leg CECS.  The addition of BoTN-A injections in this case suggests it may be a useful supplemental modality in rehabilitation for long-term benefits for CECS patients. However, further research is needed to confirm these findings in a larger population.

k Foster, s wang-price, l brizzolara, m weber, r boeth, x yuan, d rhon

Abstract accepted for platform presentation at the 2025 Combined Sections Meeting- American Physical Therapy Association

Exercise is a treatment recommended in clinical practice guidelines for low back pain (LBP). The primary purpose was to determine the impact of receiving therapeutic exercise (TE) for the management of LBP on time-to-occurrence of subsequent lower extremity (LE) injury within 1 year, in beneVciaries of the Military Health System (MHS). The secondary purpose was to examine the dosing impact (number of TE sessions) on time-to-occurrence of subsequent LE injury in beneVciaries who received TE.

Participants were placed into one of two groups: those receiving TE or those not receiving TE. Cox proportional hazards regression models were used to examine the utilization of TE and the number of TE sessions along with the demographic factors of interest on the time-to-occurrence of subsequent hip, knee, and ankle injury, respectively.

There were 452,668 patients in this cohort (mean age (SD) = 35.5(12.3), 65.2% male, 62.8% active duty; 80.6% of active duty enlisted). Only 16.5% of patients received TE, but each additional TE visit signiVcantly decreased subsequent LE injury risk. In addition, several demographic factors signiVcantly increased the risk of subsequent hip, knee, or ankle/foot injury including age, being on active duty, receiving the initial diagnosis in the emergency room (ER) or urgent care (UC), and being in the Army, whereas other factors such as being in the Navy or Coast Guard, or being an ohcer signiVcantly reduced the risk of LE injury in the year following an initial LBP diagnosis.

Following LBP diagnosis, individuals who did not receive TE had an increased risk of subsequent LE injury in the year following the episode of LBP. Further, in individuals who did receive TE, the risk of subsequent LE injury signiVcantly decreased with each additional session. The results of the study highlight the potential downstream impact and health implications of LBP, as well as information to guide to treatment and return to duty decisions after LBP.

E Anies, r Waltz, S lacey

A 49-year-old man presented with repeated episodes of right posterior knee effusions 11 months following right knee medial meniscus debridement. He was referred to Physical Medicine & Rehabilitation (PM&R) by his orthopaedic surgeon for further non-operative management. He had previously undergone ipsilateral vein stripping procedures with vascular surgery 5 months following his meniscal procedure. MRI of the knee with contrast along with a subsequent ultrasound evaluation with no evident power doppler flow confirmed the presence of a right posterior-medial gastrocnemius fluid collection extending extramuscularly into the proximal 1/3rd of the medial head of the gastrocnemius muscle. These imaging findings combined with the yellow-clear aspirate consistent with synovial fluid confirmed the presence of a Baker’s cyst with unusually distal extramuscular extension and subcutaneous location just superficial to the medial head of the gastrocnemius muscle. Successful implementation of platelet rich plasma (PRP) and Doxycycline tissue sclerosis emphasised the key role that nonoperative modalities have in treating Baker’s cysts. The patient continues to respond appropriately with resolution of his symptoms noted 3 weeks after his initial sclerotherapy session and an additional treatment performed with half the initial dose of doxycycline. This case demonstrates the successful treatment of a baker’s cyst with an unusually distal location.

Anies E P, Waltz R A, Lacey S (January 15, 2025) A Baker’s Cyst with Distal Extramuscular Extension: A Case Report. Cureus 17(1): e77502. doi:10.7759/cureus.77502

a weart, l brown, e florkiewics, g fresinger, k east, n reilly, j song, d goss

Background: Running biomechanics have been linked to the development of running-related injuries in recreational and military runners.

Purpose/Hypothesis: The purpose of this study was to determine if personal characteristics or running biomechanical variables are associated with running-related injury incidence or time to injury in military cadets undergoing training. It was hypothesized that a rearfoot strike pattern, greater rate of impact, or a lower step rate would be related to a greater running-related injury incidence and a decreased time to injury.

Study Design: Cohort study; Level of evidence, 2.

Methods: Military cadets wore an on-shoe wearable sensor that analyzed biomechanical variables of foot strike pattern, rate of impact, running pace, step rate, step length, and contact time during cadet basic training (60 days). Running-related injuries during cadet basic training were determined by medical record review. Personal and running variables between the injured and uninjured cadets were compared using independent t tests and chi-square analyses. Time to injury and hazard ratios (HRs) were estimated using Kaplan-Meier survival curves and Cox proportional hazard regression models, respectively.

Results: Of the 674 cadets who completed the study, 11% sustained a running-related injury. A significantly greater proportion of the injured participants were female (χ2 = 7.95; P = .005) and had a prior history of injury (χ2 = 7.36; P = .007). Univariate Cox proportional hazard regression models revealed greater injury risk in females (HR, 1.96; 95% CI, 1.22-3.16; P = .005) and cadets with a prior injury history (HR, 1.86; 95% CI, 1.18-2.93; P = .008). After adjusting Cox models for prior injury, females were found to be at a 1.89 times (95% CI, 1.17-3.04; P = .009) greater risk of injury. Running biomechanical variables were not associated with injury risk.

Conclusion: Study results indicated that non-modifiable risk factors such as female sex and prior injury history increased the risk of running-related injury in cadets undergoing military training. Running biomechanical variables measured by the wearable sensor were not associated with injury in this study.

Weart A., Brown L., Florkiewicz E., Freisinger G., East K., Reilly N., Song J., Goss D. (2025) Using Wearable Sensor Technology to Analyze Running Technique and Prospective Running-Related Injuries During United States Military Cadet Basic Training. Orthopaedic Journal of Sports Medicine. https://doi: 10.1177/23259671241309273

e metzger, n hager, r ory, w lucio, l wagner, b isaacson, p pasquina

Abstract accepted for poster presentation at the 2025 Big Sky Sports Medicine Conference

Photobiomodulation therapy (PBMT) involves applying non- ionizing forms of  light from various sources including lasers, light-emitting diodes (LEDs), and broadband light, in  the visible and near infrared spectrum, to biologically modulate cellular activity to enhance  healing. PBMT can enhance repair and regeneration of tissue, stimulate metabolism, and reduce  inflammation and pain during injury recovery. This program investigates the use of PBMT to treat musculoskeletal injury (MSKI) and enhance performance and recovery in United States  (US) military Service Members (SMs).

We conducted five clinical trials and one observational study at US military  installations to assess the application PBMT for MSKIs and performance and recovery.  Currently, 344 participants have enrolled. Data included objective measures and self-reports. 

When applied for plantar fasciitis (PF) and Achilles tendinopathy (AT), there were  improvements in self-reports across the injuries and treatment groups [vs. Sham for PF, and vs.  Standard of Care, extracorporeal shockwave therapy (SWT), PBMT alone, and in combination  with SWT for AT] in the Foot Functionality Captured via Foot and Ankle Ability Measure  (FAAM), Defense and Veteran Pain Rating Scale (DVPRS),Victorian Institute of Sport  Assessment-Achilles (VISA-A), University of Wisconsin Running Injury and Recovery Index  (UWRI), and Lower Extremity Functional Scale (LEFS). Objective ultrasound measures also  trended towards improvement. Further results for treating bone stress injury, general  wellness/recovery, and planned projects for performance will be available at the time of the  conference.

n hughes, b cornell, r rossi, e metzger, n hager, g gabler, l wagner, b isaacson, p pasquina

Abstract accepted for poster presentation at the 2025 Big Sky Sports Medicine Conference

Special Operations Forces (SOF) train continually to maintain peak performance,  thus, are always in a state of recovery. Photobiomodulation therapy (PBMT) is a noninvasive  low-level laser treatment to enhance healing, recovery, and performance. Studies have shown  performance and recovery benefits with focal applications of PBMT. While less evidence exists  for psychological effects of systemic PBMT applications, self-reported fatigue was found to be  lower with focal PBMT compared with placebo. Further, PBMT research in elite warfighters is  limited. The Army Tactical Human Optimization Rapid Rehabilitation and Reconditioning  (THOR3) provides a consistent setting for strength and cardiovascular training, conditioning,  nutritional and behavioral health monitoring and is an optimal setting to assess the effect of  PBMT on performance and behavioral measures. We aim to study the physiologic and  behavioral effects of PBMT, post-exercise, on performance in SOF.

We will conduct a single-blind, randomized-control trial in healthy SOF operators, assigned to receive PBMT or sham-PBMT post- training. Treatment will be administered 3  times/week for 3 weeks to both quadriceps. Objective measures include body fat percentage,  height/weight, isokinetic/isometric leg strength, Oura ring sleep/activity data, and  countermovement jump. Subjective measures include demographics, Rating of Perceived  Exertion, Short Questionnaire of Fatigue, delayed muscle soreness scale, Defense Veterans Pain  Rating Scale, and activity logs.

PBMT shows promise in accelerating musculoskeletal repair, psychological  resilience, thereby reducing injury risk and enhancing overall performance. This study may  inform standards of training and care to maximize readiness among elite warfighting units.

R rossi, j schroeder, s grogan, n hager, e metzger, g gabler, j persinger, n karikari, s mckee, b isaacson, l wagner, p pasquina

Abstract accepted for poster presentation at the 2025 Big Sky Sports Medicine Conference

Non-insertional Achilles Tendinopathy (AT) is a common overuse injury in athletes and United States military Service Members. Photobiomodulation therapy (PBMT)  delivers non-ionizing light to produce beneficial outcomes. Extracorporeal shockwave therapy  (SWT) delivers mechanical energy to the tendon and has been shown to be effective for AT. The  addition of PBMT to SWT is hypothesized to enhance these effects by increasing cellular  function and healing. Our primary aim was to evaluate PBMT, SWT, and Physical Therapy (PT)  on non-insertional AT.

Forty-five participants were randomized to: PT only, PBMT+PT, PBMT+SWT+PT, or SWT+PT. SWT treatment: 1x/week/3 weeks at 15hz for 3000 pulses. PBMT treatment: 2x/week/3 weeks at 10 J/cm2, 25W. Study duration was 6 months. Outcomes: activity logs,  pain/functional surveys, ultrasound tendon thickness measurements, and Range of Motion (ROM). 

At 3-months, all groups improved in Defense and Veterans Pain Rating Scale, Lower  Extremity Functional Scale, University of Wisconsin Running Injury and Recovery Index (PBMT+SWT+PT: + 7.1 units; p = 0.1), Patient-Reported Outcomes Measurement Information  System (6-week function scores: SWT+PT > PBMT+PT; p < .1), & Victorian Institute of Sport  Assessment-Achilles. PBMT+SWT+PT group had a Long Axis Maximal Circumference decrease of 3.1 mm (p = 0.1). Treatment with SWT increased Knee Flexed Passive Dorsiflexion  by 5.37° (p = .01). No significant intergroup differences in the above outcomes at 12-weeks (p > 0.1).

These results justify further investigation in the optimal dose/treatment frequency  of SWT+PBMT. Our findings can inform clinical treatment options for AT to optimize recovery  and return to activity.

l cin, j schroeder, c mincey, j persinger, n hager, r rossi, e metzger, c yimyam, l wagner, b isaacson, p pasquina

Abstract accepted for poster presentation at the 2025 Big Sky Sports Medicine Conference

On average, two million patients receive treatment annually for Plantar Fasciitis  (PF) in the United States. Athletes and Active-Duty Service Members are more prone to PF from repetitive foot stresses and biomechanical predispositions (high arches, excessive pronation, etc.) Photobiomodulation therapy (PBMT) uses non-ionizing light forces to enhance performance,  alleviate pain/inflammation, promote healing and may be effective in treating PF. This study  assessed the clinical effectiveness of PBMT compared to sham-PBMT for PF in Active-Duty Service Members.

Blinded participants were randomized to receive PBMT or sham-PBMT 3x/week x3  weeks at 10 J/cm2, 25W output power using the LightForce XPi and home exercises x6 weeks.  Sham-PBMT participants could crossover after 6-weeks. Outcomes included Defense and  Veterans Pain Rating Scale (DVPRS), Foot Functionality Captured via Foot and Ankle Ability  Measure (FAAM), and ultrasound measured fascial thickness.

FAAM scores improved for the PBMT group (N = 33) at 6-weeks: -17.2 points (SD:16.1; p < .01); sham-PBMT group (N = 35): -11 points (SD:17.1; p = .08); no statistically  significant intergroup differences (p > .05). Both groups experienced median absolute change in  DVPRS scores at 6 weeks: -1.0 points; no significant intergroup differences (p > .05). 6-week  median absolute change in thickness: PBMT: -.01 mm; sham-PBMT: 0.3 mm.

Both groups met the threshold for a minimum clinically important difference on the FAAM (≥ 8-point decrease) and decreased DVPRS. The PBMT group experienced a small  PF thickness decrease. These findings indicate that PBMT may be an effective adjunctive  treatment for PF pain/function.

l. cin, s grogan, j persinger, j schroeder, n hager, r rossi, e metzger, c mincey, l wagner, b isaacson, p pasquina

Abstract accepted for poster presentation at the 2025 Big Sky Sports Medicine Conference

Lower extremity injuries are common sources of disability and time loss for  athletes and military servicemembers. Microvascular flow (MVF) and shear wave elastography  (SWE) may be non-invasive, efficient, and cost effective in early diagnosis and treatment of  musculoskeletal injuries (MSKIs). This study aimed to establish normative values for routine  tendon echo-characteristics, presence/absence of plantaris tendon, MVF vs Power Doppler (PD),  and SWE measurements in the posterior lower leg and Achilles tendon.

Ultrasound was performed on asymptomatic participants using a Samsung RS-85  Prestige. Orthogonal measurements were obtained along the Achilles at the calcaneal insertion  (CI), avascular zone (AVZ), gastro-soleus junction (GSJ), medial gastrocnemius, and soleus.  Outcomes included: thickness/width 2D imaging measurements, vessel quantification in PD &  MVF, SWE analysis, plantaris tendon visualization, Body Mass Index (BMI), ankle Range of  Motion (ROM), and self-reports (demographics & activity).

MVF detected flow in 9 limbs vs 1 by PD (n = 106). Increased BMI resulted in  increased tendon/gastroc measurements: (p < .01); SWE [r(63) = 0.41] & AVZ SWE [r(63) =  .33]. Long-Axis median: GSJ height = 0.2 cm, CI = 0.4 cm, & AVZ height = 0.5 cm. Short-Axis  mean AVZ width: males = 1.5 cm (SD: 0.2), females = 1.4 cm (SD: 0.2). Plantaris tendons  identified in > 50% of study population (59 out of 106 limbs).

Our findings will inform the normal, routine, and novel ultrasound values for the  Achilles tendon complex and its related structures. This may help improve the diagnosis and  treatment of MSKIs.